In this episode of Critical Point, Milliman senior healthcare management consultant Susan Philip talks to host Lesley Pink about telehealth. Around for over 50 years, NASA developed the first form of telemedicine to monitor astronauts in space. Today, telehealth is being used to deliver healthcare in the U.S. to a population that might otherwise have difficulty accessing care. Susan Philip joins Critical Point to provide a primer on telehealth including its uses, regulatory landscape, efficacy, and some of the ground-breaking new devices using telehealth to deliver care.

Transcript

Disclaimer: This podcast is intended solely for educational purposes and presents information of a general nature. It is not intended to guide or determine any specific individual situation, and persons should consult qualified professionals before taking specific action. The views expressed in this podcast are those of the speakers and not those of Milliman.

Lesley Pink: Hello and welcome to Critical Point, brought to you by Milliman. I'm Lesley Pink and I'll be your host today. In this episode of Critical Point, we're going to be talking about telehealth. Milliman consultants have written a number of papers on telehealth. Some of the topics covered include telehealth under alternative payment model and telemedicine and the long-tail problem. Joining us today is Susan Philip, a senior healthcare management consultant from our San Francisco office, who was an author on those two papers. Susan has nearly 20 years of experience in health policy, healthcare finance and health services research with federal and state governments, academia, and the nonprofit sector. She has worked with clients on strategies for telehealth, telemedicine, financing, and adoption. Welcome, Susan.

Susan Philip: Hi, Lesley. Thanks so much for having me here.

Lesley Pink: Let's start with a general definition of telehealth. What is it and what areas does it encompass?

Susan Philip: Sure. I think many folks have heard the term telehealth and they might've heard other terms also such as telemedicine, virtual visits, and remote patient monitoring. All of these describe telecommunication technologies that are really essentially trying to connect the patient with the clinician for really the care the patient needs, and I think there's been a lot of excitement about telehealth and the promises that it might hold to improve access and convenience and even quality of care. One important point I'd really like to emphasize about telehealth is that it really is a modality of delivering healthcare services. It's not an intervention in and of itself, right. It's really about getting care to patients when they need it in a way that's convenient and easy for them to access.

Lesley Pink: Speaking of that, how would you break down the different elements of telehealth? Can you tell us a bit about some of the different areas?

Susan Philip: Yeah, I would say there are a few different telehealth types. First, you have what you might think of as live video. So this is essentially live, two-way interaction between the patient and their doctor using some kind of audiovisual technology and then you have something called store-and-forward and that-- the concept there is you're basically capturing patient information and say like a digital photo, a digital image, and then transmitting that information to a practitioner that's in a different location and so, in that sense, it's not real-time because you have the information that's being captured from the patient and then being remotely delivered to the practitioner. Then you have what we call remote patient monitoring, and that is basically collecting personal health and medical data from an individual in a certain location and then transmitting it to a practitioner, usually a care manager, for example, in another location and this is really done in the context of a larger care management program. So, for example, you've got a patient that's been discharged from a hospital. They-- that patient just had heart surgery. They're sent home with a couple of devices that are Bluetooth enabled. That information that is being collected from the devices is then sent to an app and then the app is transmitting information to a remote care manager that is then looking at the information and using that to provide care management to that patient.

Lesley Pink: So telehealth encompasses many different areas.

Susan Philip: Yeah. Live video, store-and-forward, remote patient monitoring I would say are the three big ones. I will also add that you've got a broader term called digital health tools or mHealth and those are really-- it's a much broader definition and it can be used to describe patient education, patient engagement tools. You don't necessarily have a human being on the other side. It could be enabled by AI or some other type of platform to do things like engage a patient in healthy behavior or to improve medication adherence. So those were the kinds of applications that are used broader in mHealth.

Lesley Pink: And let's talk a little bit about the history of telehealth. When did it come into existence and why did it come into existence?

Susan Philip: So I think this is interesting. Telehealth has been around and has been going on for over 50 years. NASA actually first developed some form of telemedicine really as a way to monitor astronauts in space and then they were thinking about ways to apply this to the earth. So the first thing they did was trying to-- they were trying to develop a technology to study the effects of gravity on circulation and respiration and then on the physiological effects of the human body and then eventually they did take that technology and say, “How could we apply this to terrestrial solutions?” So another early example dates back to the early 1960s. At that time, the Nebraska Psychiatric Institute began providing consultation services to a remote state mental health hospital and they use closed circuit television system and that was really a way for them to be able to see patients and be able to provide the practitioners who were in that remote mental health hospital and provide them direct services through an audiovisual tool.

Lesley Pink: Speaking of that, where is telehealth being used the most now in the U.S. and what specific populations are using telehealth?

Susan Philip: Yeah, I think right now telehealth, in its traditional form, has really-- is really being used in rural areas and that kind of makes sense because we're talking about areas without certain practitioners. There's health professional shortages. So, for example, let's take the state of Iowa. Iowa has been dealing with a psychiatric shortage for years. Eighty-nine of the state’s 99 counties have a mental health professional shortage and that's according to the federal agency Health Resources Services Administration. So that's an example of where you've got some serious health professional shortages and telehealth can really help connect a psychiatrist and mental health provider with patients, and I do think that the need for telehealth in rural communities is really going to become even more pressing with the opioid epidemic and as communities really struggle to find mental health and substance use treatment for their populations.

Lesley Pink: And this leads to my next question, which is what are some of the major benefits? One is providing access to people who might not normally have it. What are some of the other benefits?

Susan Philip: I would say the biggest benefit of telehealth and the promise that it holds is that it is a way of providing healthcare services to a patient at the time they need it and it really reduces barriers to access. So one application of telehealth and hope for telehealth is that perhaps it can be used to prevent more serious exacerbations of a condition, stop a condition from getting worse because you're getting a patient the care they need at the time they need it. So can you prevent really expensive emergency department visits and so I think that's a potential area for it to really provide benefits.

Lesley Pink: Has there been any research done yet on the effectiveness of telehealth as compared to in-person visits?

Susan Philip: So there has been quite a lot of research and recently a federal agency called the Agency for Health Research and Quality had produced a review of all the evidence on telehealth and they came up with the conclusion based on the current evidentiary base that telehealth interventions really produces positive outcomes for remote patient monitoring, what I just mentioned earlier as an example, and really for certain types of chronic conditions such as cardiovascular and respiratory disease and for those patients, it's been found to actually reduce hospital admissions. Psychotherapy was also another area with a strong evidentiary support as part of a behavioral healthcare program. Now, there is some concern about telehealth’s effects on cost and utilization. If you are making healthcare more accessible, then presumably more people will be using it and that does have some implications for healthcare costs. So there's some concern that telehealth, for say, nonemergency, primary care type services might drive up overall healthcare utilization because in some cases, it might not be a substitute for a higher cost service, but it is in fact a new service and if a person has a telehealth visit and then they have to have a follow-up, in-person visit, then you've got a couple of more visits versus a reduced visit. So there is some concern about this new modality of services driving up overall healthcare use and costs.

Lesley Pink: And who has jurisdiction over telehealth since it's online, since it's via the phone? How does that work?

Susan Philip: Yes, well, the regulatory world of healthcare and telehealth is complicated. So if I were a provider of telehealth, the first thing I would want to know is who is a payer? Is it Medicare? Is it Medicaid? Is it commercial and under each of those, different rules apply. Whether a telehealth visit is covered will depend on the payer type. So that's one thing to consider: who's the payer and is it covered? If the beneficiary or the member is a Medicaid member, then the rules vary by every state. So, for example, in the state of California, a Medicaid member has coverage for store-and-forward for teledermatology, whereas that might not be the case in another state, and Medicare's definition of telehealth is actually quite restricted. It's restricted to real-time live video. So no store-and-forward except for two states, so it's restricted to real-time live video and audio communication between the patient and a provider at a distant site and the patient-- where the patient is matters. So there's two types of restrictions: call originating site and geographic restrictions. So the patient must be at a certain originating site, which means they either have to be in a doctor's office or they have to be in a hospital or they have to be at a certain location that is on the approved list of originating sites. The home is not an approved originating site. So that is a current restriction under Medicare and then you have a geographic restriction, which right now Medicare only covers telehealth for rural areas. So, that in and of itself, those two restrictions are pretty big restrictions under Medicare, but I will say those rules are changing and becoming more relaxed.

Lesley Pink: Where do you think telehealth has the capacity to be the most useful, the most effective? Are there specific populations that it's especially suited for?

Susan Philip: So I think that telehealth has a lot of promise to serve people with mental health and substance use needs. According to the CDC, the latest statistics from 2016, there have been 42,000 people who have died in the U.S. from an opioid overdose. So these are really concerning estimates and all signs indicate that that has not abated at this point. So there's been a lot of attention on how we can address the opioid epidemic and telehealth is potentially a solution in helping connect mental health providers and substance use providers with patients. So, one of the-- there's actually a bill that is just working its way through Congress now that would allow the loosening of these Medicare restrictions on these originating site requirements. So eliminating that requirement for substance use disorder treatment and it would also allow for coverage of substance use treatment for people in non-rural areas. So urban areas and suburban areas. So I think that really is-- assuming that that passes and there is actually quite a lot of bipartisan support when it comes to mental health treatment and the opioid epidemic. So if that were to pass, I think that will really open up a lot of doors.

Lesley Pink: And on that note, you're based in California and it seems like that state is at the forefront of telehealth. Can you tell us some things that California is doing?

Susan Philip: Yeah, I think California has done quite a bit from the regulatory side as well as just the market and what the private industry has been doing. So from the regulatory side, one thing that they have made explicit in law is certain types of store-and-forward is covered. As I mentioned before, under Medicaid, teledermatology is covered. Also, teleoptometry is also covered for the Medicaid population. So, in that sense, it's allowed for additional specialty services to be covered under Medicaid. So, from the private sector side, we really are seeing quite a few companies, especially newer startups, that are interested in the healthcare space and are leveraging telehealth visits to better engage patients, especially in their own healthcare. They are also trying to figure out what are the other needs of a patient. So, for example, I've seen some interesting solutions that first have a patient engage with the app or with a solution with a telehealth visit. But then through that engagement, they find out other services that a patient might need. So, for example, are they at risk for housing issues and do they then get connected to social services? Are there potential financial literacy tools that they could benefit from? So these are actually addressing a wide range of not just traditional healthcare needs, but other social services needs that a patient might need.

Lesley Pink: What do you think the future of telehealth will be? Is there anything especially exciting or interesting on the horizon?

Susan Philip: Well, I do think that the fact that Medicare is loosening some of its requirements. So, for example, under the Medicare shared savings program, a number of providers that participate in that program are now going to be able to provide telehealth to their beneficiaries, including folks that are not-- including folks who are not in rural areas and can also provide healthcare services and telehealth to patients in their home. So I think that is really exciting because it does open up a whole new set of doors to treat patients and provide additional care management for elderly patients in their home. So the other area that I think telehealth holds a lot of promise is these new devices and new technologies. So, for example, last year there was a device that the FDA had approved to allow certain drugs to be monitored through a pill that you swallow. So it's essentially a digital pill that has sensors that you swallow and that is then used to essentially journal how the patient is doing in terms of taking their medication. So are they adherent and are they actually taking their meds? The only way you really can tell a patient's taking their meds? If it actually went down their throat. So I think that's very interesting. It's a whole different world of monitoring and patient adherence. We'll see how much uptake there is and how much provider comfort and how much patient comfort there is, because those two things are necessary to increase adoption and I will say-- maybe an obvious point-- but there's going to continue to be demand for convenient access to care. In every aspect of our lives, we have ready access to pretty much everything. We can do our finances on our phones. We can access and reach all sorts of services through our mobile devices. So why not be able to reach your healthcare practitioner? So I think there's just going to be increased demand over time and that does have implications for healthcare use and cost. So that's something to continue to monitor and, of course, you want to make sure that patients are actually getting effective care from their providers that are in a different location.

Lesley Pink: Thank you, Susan, for joining us. You've been listening to Critical Point presented by Milliman. To listen to other episodes of our podcast, please visit us at milliman.com or find us on iTunes, Google Play, Spotify, and Stitcher. See you next time.